Medical students creating their own oaths: Is that the best way to enter the profession?

As the fall approaches, medical schools across the country are preparing for the arrival of a new crop of medical students. The primary emphasis of medical school is to teach technical competencies so that students graduate with the medical knowledge and know-how to diagnose and treat disease.  Recognizing the health care is getting more and more complex, schools are also introducing new and evolving fields like health systems science, interprofessional education, and medical ethics as standard parts of the medical school curriculum, so that students learn to think more holistically while managing various stakeholders as they provide care.

Additionally, professionalism has become a major learning objective in medical education, but it is both challenging to instruct and to assess.  Professionalism is much more than simply showing up on time, appropriately dressed and smiling. It demands that students develop their own sense of self as a doctor – and recognizes that their goals and desires may come in conflict with what is expected of them. Doctors must figure out how to incorporate both their own personal values and the values and norms of the profession they committed themselves to join. Acceptance of this type of self-sacrifice can only come with time and experience and is not easily taught.

In order to introduce the concept of professionalism to medical students, many medical schools organize a White Coat Ceremony to underscore that medical school is more than just teaching medical knowledge. Since its creation in 1993 by the Arnold P. Gold Foundation, the White Coat Ceremony has become a rite of passage for newly-minted medical students. During this event, a white coat is placed on the students’ shoulders signifying that they are now part of something larger than themselves – they are doctors-in-training. Through this ceremony, students begin to realize that they are not simply going to school, rather they should see the next four years as a personal transformation where class instruction and self-reflection are required.

The White Coat Ceremony is a great way to introduce students to the idea that the profession is not of their own making, but rather something larger than themselves. However, this message is diluted in some medical schools that have instituted the practice of having the entering class create their own medical student oath that they recite at the White Coat Ceremony. Those who advocate for students constructing their own oath claim that the purpose of this exercise is to provide students with an opportunity to think about the gravity of the undertaking on which they are about to embark. In creating their own oath, the hope is that students will internalize the values of the profession more quickly and more earnestly.

Yet, in having students construct their own oath, medical schools may unwittingly be creating a situation where students do not fully understand exactly what is expected of them in this profession. Constructing their own oath may reinforce the idea that their commitment to the profession is only a commitment to what they personally already value. For example, in describing his experience in constructing a professional oath, one student stated, “The oath expresses the values we wish to adhere to and lays out the path we will now begin to walk.”  However, one’s training to enter the medical profession should not start with what the student expects from the profession; it should start with what the medical profession expects of its professionals.

Rather than having students construct their own oath as a way to help students form their professional identity, it may be more conducive for them to discuss — with upper classmates and clinical faculty — the tension between their own personal values and those of the profession they hope to enter.  Between Orientation Week and the White Coat Ceremony, students should have opportunities to meet with older students and faculty mentors, who can introduce them to some of the professional expectations which with they may not yet be aware and provide them with certain strategies to prepare them for what’s to come.

Students should also have some time in small groups to reflect on what the profession demands and anticipate any tensions that may arise between their personal and professional goals and desires.  At the White Coat Ceremony, the class can construct an affirmation where they recognize they are preparing to enter the medical profession, and they understand the gravity and responsibility that the profession demands.  They can then commit to pursuing that challenge and learning what that means along the way.  Thinking through how they will maintain personal and professional integrity in times of potential conflict might serve their professional identity formation better than having them commit to something of their own making.

It is important for students to learn and internalize the ethos of the profession, but this transformative process takes time. Constructing one’s own oath of commitment is more akin to shooting an arrow and then drawing the target, instead of developing the skills to hit the bull’s eye.

Ira Bedzow is an assistant professor of medicine and director, medical ethics program, New York Medical College, Valhalla, NY.

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